Cases & Commentaries

Caution, Interrupted

Commentary By Robert L. Wears, MD, MS

The Case

A 55-year-old man with acute myelogenous leukemia
and several recent hospitalizations for fever and neutropenia
presented to the emergency department (ED) with fever and
hypotension. After assessment by the emergency physician,
administration of intravenous crystalloid and empiric
broad-spectrum antibiotics, the patient was assessed by his
oncologist. Based on the patient's several recent admissions and
the results of a blood culture drawn during the last admission, the
oncologist added an order for Diflucan (fluconazole) 100 mg IV to
cover a possible fungal infection.

Because intravenous fluconazole was not kept in
the ED, the nurse phoned the pharmacy to send the medication as
soon as possible. A 50 ml bottle of Diprivan (propofol, an
intravenous sedative-hypnotic commonly used in anesthesia) that had
been mistakenly labeled in the pharmacy as "Diflucan 100 mg/50 mL"
was sent to the emergency department. Because the nurse also worked
in the medical intensive care unit, she was quite familiar with
both intravenous Diflucan and Diprivan. When a glass bottle
containing an opaque liquid arrived instead of the plastic bag
containing a clear solution that she expected, she thought that
something might be amiss.

As she was about to telephone the pharmacy for
clarification, a physician demanding her immediate assistance with
another patient distracted her. Several minutes later, when she
re-entered the room of the leukemia patient, she forgot what she
had been planning to do before the interruption and simply hung the
medication, connecting the bottle of Diprivan to the patient's
subclavian line.

The patient's IV pump alarmed less than one
minute later due to air in the line. Fortunately, in removing the
air from the line, the nurse again noted the unusual appearance of
the "Diflucan" and realized that she had been distracted before she
could pursue the matter with the pharmacy. She stopped the infusion
immediately and sent the bottle back to the pharmacy, which
confirmed that Diprivan had mistakenly been dispensed in place of
Diflucan.

The patient experienced no adverse
effects—presumably he received none of the Diprivan, given
the air in the line, the infusion time of less than a minute, and
the absence of clinical effect (Diprivan is a rapidly-acting
agent). Nonetheless, the ED and pharmacy flagged this as a
potentially fatal medication error and pursued a joint,
interdisciplinary root cause
analysis, which identified the following contributing factors:
(i) Nearly 600 orders of medication labels are manually prepared
and sorted daily; (ii) Labels are printed in "batch" by floor
instead of by drug; (iii) The medications have "look-alike" brand
names; (iv) A pharmacy technician trainee was working in IV
medication preparation room at the time; and (v) The nurse had been
"yelled at" the day before by another physician—she
attributed her immediate and total diversion of attention in large
part to her fear of a similar episode.

The Commentary

Interruptions, Distractions, and Multitasking:
Ubiquitous Threats to Patient Safety

This "near miss" is rich,
complex, and subtle. It illustrates how the "messy details" of
technical work—those factors investigators would usually like
to ignore or eliminate—are in fact the most important objects
of study, if we are to gain a deeper understanding of the genesis
of success or failure in medical work.(1) Viewing this case as only an issue of mislabeling
involving look-alike and sound-alike drug names misses much of its
value.

Interruptions

Although this specific incident involves the
interruption and distraction of a nurse, the general issue of
interruptions and distractions relates to physicians' daily work as
well. Particularly in high tempo settings, such as the emergency
department, health care workers are immersed in a flood of
communications, interruptions, distractions, notifications, and
alarms. Emergency physicians are interrupted, on average, nearly
once every 5 minutes, and, perhaps more concerning, two thirds of
those interruptions lead to a change in task.(2) Coeira and colleagues observed nurses and doctors in
emergency departments and found that for both groups, about 80% of
their time was taken up with communications activities.(3)
During much of this time, the workers were also engaged in other
tasks, and for an important fraction of it, they were involved in
two or more simultaneous conversations.

Interruptions, distractions, and multitasking
have long been associated with process failures. Almost half of
National Transportation Safety Board (NTSB) investigations identify
lapses of attention or divided attention (associated with
interruptions or distractions) as contributors to the
accident.(4)

But, while the high communications loads,
interruptions, and distractions faced by health care workers are
stressful and sometimes exceed the capacity of "merely
extraordinary" human beings to keep up, at the same time, safety
and productive performance in high-risk environments depend
strongly on continuous communication and rapid updating of
information.(5)
Similarly, interruptions can be important if attention must be
quickly redirected to urgent matters. Thus, a simplistic approach
to reducing the volume of communications and interruptions may
inadvertently make things worse instead of better. Even
communications that are nominally unimportant (for example, because
they are directed to someone other than the provider in question)
may play a latent role in maintaining awareness of the ambient
environment. Experts often monitor normal operations by listening
to the background "chatter," not attending to any specific
communication, but being alerted when the pattern of activity
changes. Making communications and interruptions more useful and
less distracting requires a careful balancing (4) of benefits and risks, informed by a deep, nuanced
knowledge of the way technical work is performed at the "sharp end." It is ironic
that the two factors that kept this case from becoming a tragedy
were (i) an "error" (air in the IV line) and (ii) an interruption
(the infusion pump alarming).

Health care workers often fail to consider the
potential impact of their interruptions on others.(3,6) Moreover, current technological "solutions" to
communications problems never show regard for others. Beepers,
telephones, overhead pagers, and alarms never ask "Is this a good
time?" or watch for a break in activity in which to insert
themselves, balancing intrusiveness against importance as a
thoughtful colleague might. Research on how to make technological
aids more cooperative and less intrusive would be valuable before
such devices are inserted into the complex environment of health
care.

The Task

The nature of the task determines to a large and
generally unappreciated extent the kinds of failures that may
occur. Here, two task factors contributed to the nurse's failure to
recognize that the wrong drug had been sent. First, she was
traveling a seldom-traversed path in the web of activities
associated with drug administration; calling the pharmacy to
question drug correctness is (happily) not often required. Second,
there was no natural cueing to the order of tasks; starting the
infusion could easily be done with or without calling the pharmacy.
When one step in a sequence does not depend on the prior successful
completion of a previous step, or when the point at which to resume
the task is not clearly represented in the work itself, steps are
much more vulnerable to being omitted, or being performed out of
order.(7) In
such circumstances, it is quite easy to resume work after an
interruption at a more "typical" spot—here, starting the
infusion—since that is more familiar, is not precluded by
omitting the call, and is suggested by the work environment (drug
bottle sitting beside infusion pump but not connected).(8)

The Social Structure

Although much of the writing about emergency
departments concerns biology, the most important things that happen
there are social.(9) We
do not know what the "getting yelled at" episode in this case was,
but we do know that such behavior is common in the health care
workplace and has negative effects on safety and performance. A
2003 survey of nurses and pharmacists reported that almost 90% had
experienced intimidating behavior such as condescending language,
and roughly half had experienced strong verbal abuse or threatening
body language.(10)
Such experiences alter caregivers' behaviors; almost three quarters
of respondents reported deviating from normal procedures in order
to avoid having to deal with a problematic provider. In addition,
nurses routinely seek advice from those socially close to them,
rather than from those best positioned to solve the
problem.(11)
The nurse in this situation did not feel that she could speak up;
this reinforces authority
gradients and inhibits the flow of potentially important
information.(12)
The aviation industry has institutionalized specific training to
prevent this from happening.(13)
The training focuses on flattening hierarchies and providing
appropriate assertion tools for those lower in authority. For those
higher in authority, the focus is on avoiding potentially
intimidating behaviors and on actively eliciting information from
others. Similar efforts have begun in some areas of health care
(14),
but have yet to be implemented in a comprehensive and sustained
manner.

What Can Be Done?

Substantive improvements in the problems
illustrated by this case will require a type of research that is
new to health care, called "technical work studies."(15) Such studies will require collaborations between
"safety scientists" (psychologists, engineers, human factors
professionals, etc.) and health care providers. The research will
need to focus on identifying the factors that make seemingly simple
tasks (such as hanging an IV medication) hard; how vulnerabilities
are detected; how workers negotiate these tasks (usually
successfully, but occasionally not); and particularly, how new
technology affects all the foregoing. Such baseline knowledge is a
prerequisite for understanding whether a given intervention will
work, in what contexts, and with what unintended consequences.

However, simply waiting for further research will
be unsatisfactory for many. Although the available evidence is
slim, some simple interventions have been suggested to begin
addressing these issues. These include measures such as creating
separate medication rooms with restricted entry to decrease
interruptions during medication preparation; or identifying
critical periods in briefly risky procedures where interruptions
should be restricted to those of the highest urgency (for example,
during emergency airway management).

Take-Home Points

  • Interruptions are both beneficial
    and detrimental to safe performance. Only knowledge of the outcome
    determines when an interruption becomes a distraction.
  • Consider
    identifying critical tasks during which interruptions should be
    minimized (eg, emergency airway management, medication
    preparation).
  • Establish a code of conduct to reduce intimidating
    behaviors.
  • Use caution when
    changing communications patterns, particularly when moving from
    rich (eg, face-to-face) to relatively impoverished (eg,
    tape-recorded) channels.

Robert L, Wears, MD, MS
Professor of Emergency Medicine
University of Florida, Jacksonville

References

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The messy details: insights from technical work studies in health
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2. Chisholm CD,
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3. Coiera EW,
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4. Dismukes K, Young
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6. Coiera E, Tombs V.
Communication behaviours in a hospital setting: an observational
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7. Reason J.
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8. Edwards MB,
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9. Vosk A, Milofsky
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February 2002;3ff.

10. Intimidation:
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[ go to related site ]. Accessed August 11,
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11. Tucker AL,
Edmondson AC. Why hospitals don't learn from failures:
organizational and psychological dynamics that inhibit system
change. Calif Manage Rev. 2003;45:55-72.

12. Morrison EW,
Milliken FJ. Organizational silence: a barrier to change and
development in a pluralistic world. Acad Manage Rev.
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13. Helmreich RL,
Merritt AC. Culture at work in aviation and medicine. Aldershot,
UK: Ashgate Publishing; 1998.

14. Morey JC, Simon
R, Jay GD, Rice MM. A transition from aviation crew resource
management to hospital emergency departments: the Medteams story.
In: Proceedings of the 12th International Symposium on Aviation
Psychology. Columbus, OH: Ohio State University;
2003.

15. Barley SR, Orr
JE, eds. Between craft and science: technical work studies in US
settings. Ithaca, NY: Cornell University Press;
1997.